Prostate Cancer and the M-to-F Transsexual

In spring, 2001, I was diagnosed with prostate cancer -- at age 54. I was still living as male, and in total denial that I was or could ever be a transsexual.

Prostate cancer becomes increasingly more common among men as they age; detection of prostate cancer when a man is in his 70's is most common (refer to the excellent Wikipedia article on prostate cancer, http://en.wikipedia.org/wiki/Prostate_cancer ), so diagnosis at age 54 is less common.

I have to say, though, that when the urologist told me in March, 2001, that a biopsy was positive for prostate cancer, I was not surprised. I had had too much bad feeling about my male genitalia for too long. If you are transgendered, be sure your primary care physician checks your blood for PSA (prostate-specific antibodies), which is an early indicator of prostate cancer. New indicators are being researched, too.

Treatment

There are both surgical and non-surgical methods of treating prostate cancer; see your local library for some of the many books on this topic (I read 5 of them after my diagnosis), and well as researching Wikipedia and other online sources.

I chose traditional surgical removal; the method was technically known as suprapubic radical prostatectomy. That means that the incision was above (supra) the pubic bone, and the incision ran from just below my navel to just above the pubic bone. My scar looks similar to the scar from a Casarean section in a woman.

It is also possible to remove the prosate by an incision through the perineum (between the scrotum and the anus). This method involves cutting through fewer layers of muscle tissue, and is likely to heal more quickly than a suprapubic removal.

Then there is laparoscopic prostatectomy, in which the prostate is removed by a surgeon using a laparoscope -- kind of like little tools at the end of wires. Very small incisions are made, so the digestive and excretory systems are not disturbed as severely as they are with suprapubic or perineal incisions, and healing is much faster.

Older men, or men with health conditions that make surgery inadvisable, can be treated with radiation. External radiation can be used, or radioactive pellets can be inserted into the prostate, usually through the perineum. Radiation has its own risks, and collateral damage to the rectum and urinary tract can be minimized but is inevitable.

Please read up on these methods if you are diagnosed with prostate cancer. I am not a doctor, and the few paragraphs here don't have enough information to enable you to have an informed judgement. Your public library surely has several excellent books on the topic.

I mention these treatment methods because they occur in the area of the body that is involved with male-to-female sex reassignment surgery (SRS).

Surgical Effects

Please bear with me until I find adequate illustrations of the area. The most common drawings of the prostate are from angles that do not show the interaction with a neo-vagina -- which is what you will get with a vaginoplasty.

The prostate resides just below the urinary bladder, and wraps around the urethra. Practically speaking, it is not possible to cut the prostate away from the urethra; instead, the urethra and prostate are removed together. This practice is not simply for the surgeon's convenience: the patient is not safe until every last cancer cell has been removed. Any cancer cells that have grown into the urethral walls could cause the cancer to recur some time in the future.

So, they chop out the whole thing, prostate, urethra, and some margin of surrounding tissue to make sure they removed all cancerous cells. The patient is left with a gap of 1-1/2 inches (3-4cm) between the cut end of the urethra and the bladder.

The lower end of the urethra is at the end of the penis. In most men, the penis lengthens as well as increasing in diameter when the erectile tissue fills with blood. If the surgeon simply pulled the upper end of the urethra to the bladder and sutured it in place, well, there would probably be enough elasticity in the tissue to permit that -- until the patient got erect, then either the incision would pull open, or the the patient would experience considerable pain. Neither of those is a good outcome.

The corrective action is to relocate the bladder lower in the abdominal cavity, possibly as low as the pubic bone itself. Relocating the bladder this way enables the surgeon to attach the urethra back to the bladder without significantly altering the position of the exterior end of the urethra. The result is that -- all other things being equal -- the patient can have an erection without putting mechanical tension on the internal sutures.

In the absence of other information, the urologist normally assumes that he is treating a typical heterosexual male. Note that this is in the absence of other information. If you are homosexual, bisexual, or transgendered, please find a way to tell your doctor. Even if you are "only" a crossdresser, or "only" a transvestite, please tell your doctor. It is very unlikely that you are the first such patient the urologist has encountered -- though you may be the first to confront the issues openly. This knowledge may enable your urologist to make a recommendation that will be more flexible for your future.

For myself, I was too deep in the closet to tell my surgeon. I sort of, kind of, tried to say, well, if I couldn't have an erection again that wouldn't be too bad, but I don't think he heard me. Besides, I had all kinds of negative things to say about transsexuals. I was sure at that time that there was never ever any way that I could become transsexual. Today, of course, I am a post-operative transsexual. (How that happened is another story.)

By the way, the books I read about prostate cancer assured me that it was not necessary for a man to have an erect penis in order to have an orgasm. It's true! If enough of the nerves are left intact, adequate stimulation can cause the orgasmic response to occur even when the penis is quite soft. This was a Good Thing for me, because I never regained sufficient erectile function for coitus. (I was still married. How we coped is the subject for another essay, yet to be written, but it is part of how a transgendered person relates to a spouse.)

Impact on Vaginoplasty

Relocating the bladder lower in the abdominal cavity makes it occupy the space that your gender surgeon would otherwise use for your neo-vagina. As a post-prostate-cancer survivor whose prostate has been removed, two conditions occur that impact your neo-vagina and its functioning:

1. Instead of 4 to 6 inches of depth for the neo-vagina, there is now only an inch or two available. Despite the best efforts of the SRS surgeon, the vaginolpasty incision will hit scar tissue from the relocation of the bladder before the surgeon is able to reach the depth that is normally obtained.
2. In a patient with a prostate, the neo-vagina will reside close to the prostate inside the lower abdomen, just above the pubic bone. Consequently, the movement of an object within the neo-vagina (whether penis or sex toy) will at some point press upon the prostate through the walls of the neo-vagina, and stimulate it. This would be similar to the stimulation a man would experience were he to have anal intercourse. That is, normally stimulation of the prostate feels REAL good, but as a survivor of prostate cancer now without a prostate, this pleasure would not be available to you and your new vagina.

I was not adequately aware of either of these points before my SRS surgery. There were discussions of depth, but I don't think that any of the SRS surgeons I spoke to were aware that the bladder is normally relocated because of the removal of the prostate.

Implications for You

If you are transgendered or a crossdresser or transvestite, then maybe in some distant universe, when you're 130 years old, you might possibly become be a transsexual; I know that could happen because it happened to me. So first of all you must open the topic with your cancer urologist, for these reasons:

1. You need to grow enough to face who you really are, and to discuss it.
2. There may be other surgical alternatives that would make SRS less challenging in the future. Unless your urological oncologist knows that these issues need to be considered, there is no need to do so.
3. Knowing that you are transgendered may help you and your urologist tip the balance toward radiation instead of surgery. Or, SRS might be a way of treating your prostate cancer -- and a way that being medically necessary might be covered by your health insurance. After all, before the 1980's, castration was the best way to treat prostate cancer.

I don't know what happens to the prostate after the tissue has been killed with radiation. Yes, the prostate cells and the cancer cells die, but what happens then? After the dead tissue has been reabsorbed into the body, does your bladder gradually swell to fill the space? If so, that might be a better choice if you need SRS in the future. On the other hand, scar tissue from the radiation may be as bad or worse than scar tissue from surger.

You must talk about these issues with your doctor if you are diagnosed with prostate cancer. Please come out of denial enough to protect your future: discuss your situation with your urologist.